In Defense of the Pickwickian Syndrome

Henry Ford Hospital Medical Journal

Volume 33 Number 1 Article 6

3-1985

Howard Markel

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Recommended Citation Markel, Howard (1985) "In Defense of the Pickwickian Syndrome," Henry Ford Hospital Medical Journal : Vol. 33 : No. 1 , 24-26. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol33/iss1/6

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med J Vol 33, No 1, 1985

In Defense of the Pickwickian Syndrome

Howard Markel, AB^

In 1956, Burwell, et al investigated the association of draw from literature to 'enrich' medical terminology. obesity, somnolence, twitching, cyanosis, periodic res Such errors rarely advance and usually retard medical piration, and right ventricular hypertrophy and failure science" (7). (1). Interestingly, many studied this striking con One of Comroe's objections concerning "Pickwickian" stellation of symptoms prior to 1956. Kryger (2) recently was that the term refers only to members of the Pick noted similar symptoms in Dionysius, the tyrant leader wick Club, founded by Samuel Pickwick, Yet, as Com of Heracleia in Pontus duringthe reign of Alexander the roe and others correctly pointed out, Joe the Fat Boy Great (c 360 AD). John Fothergill, an eighteenth century was not a member of the Pickwick Club, Joe the Fat British physician, described an interesting patient who Boy's lack of status in that esteemed organization is, was obese with a "fresh sanguine complexion, per however, information that has been easily accessible for petual drowsiness, and . . . such a degree of som over 140 years and is not crucial to the controversy nolency . . . that he could scarce keep awake whilst he about the name. I should like to "pass over the 'charm described his situation" (3). William Wadd, Surgeon ing' literature error" and defend the clinical aspects oi Extraordinary to the King of England in 1822 wrote: "We Dicken's description of the syndrome. find the pulse of fat people weaker than in others and from these circumstances also we may easily under Another important consideration is that two types stand how the corpulent grow dull, sleepy, and indo obesity-sleep apnea have been classified. In the first lent. . . . [One patient] became at length so lethargic type, patients have apnea during sleep but have normal that he frequently fell asleep in the act of eating, even in ventilation and drive to breathe while awake (2). The company" (4). second type of patient suffers from hypoventilatio while awake as well as sleep apnea; the latter is the tru William Osier (1849-1919), as talented a scholar of his "Pickwickian" noted by Burwell (1). tory and literature as he was of medicine, noted a classic Before the medical world dispenses with the name description ofthese symptoms, in Charles Dickens' first Pickwickian syndrome in favor of something like novel. The Posthumous Papers of the Pickwick Club "obesity-hypoventilation syndrome," it ought to recon (1836-1837) and proposed the term "Pickwickian" in sider Dickens' history of Joe the Fat Boy. This com reference to these fat, sleepy people in his famed text parison is worthwhile for two reasons. First, "medicine book of medicine (5). Burwell and his coworkers further needs all the ties to the broad stream of human culture defined the major features of the syndrome giving great that it can develop" (10). Second, a change in termi-l importance to the name Pickwickian syndrome because nology would deprive Charles Dickens of credit fori they paralleled, as Osier noted, the characteristics of creating "still the single most accurate description oti Joe, a "fat and red-faced boy in a state of somnolency," a minor character in The Pickwick Papers (6). the syndrome" (10). Dickens' description of Joe the Fat Boy does, indeed, present a cohesive and nearly complete description ofa, It should also be noted that Dickens refers to Joe as "Young Dropsey," "Young Opium-Eater," and "Young patient suffering from the "Pickwickian syndrome": Boa Constrictor" in reference to his obesity, lethargy, A most violent and startling knocking was heard at and enormous eating habits, respectively (6). One of the door; it was notan ordinary double knock, but the most striking features of the syndrome is the re a constant and uninterrupted succession of the markable degree of drowsiness the patient experi loudest single raps, as if the knocker were en ences, causing sleep to overcome the patient in the dowed with the perpetual motion, or the person course of ordinary activities. outside had forgotten to leave off.

Interestingly, the eponym "Pickwickian syndrome" has Submitted for publication: January 23, 1985 Accepted for publication: April 18, 1985 generated a good deal of controversy. Comroe (7), Vaisrub (8), and Keelan (9) take exception to the Dick- •Third-year Medical Student, University of Michigan Medical School ensian appellation. Comroe stated that "errors pop up Address reprint requests to Mr Howard Markel, 1350 W Bethune, #804, Detroit over-and-over whenever medical scientists decide to Ml 48202.

24 Defense of Pickwickian Syndrome

Mr Lowton hurried to the door.. . .The object that use of an electrocardiogram, electroencephalogram, presented itself to the eyes of the astonished clerk oral spirogram, electro-oculogram, and diaphragmatic was a boy—a wonderfully fat boy— . . . standing electromyogram. Gastaut, et al showed that some Pick upright on the mat, with his eyes closed as if in wickian patients do not breathe normally at night, since sleep- He had never seen such a fat boy, in or out their sleep is interrupted by at least two types of apnea. of a traveling caravan; and this coupled with the The first is central apnea, in which the patient does not utter calmness and repose of his appearance, so make an effort to breathe, while the second is obstruc very different from what was reasonably to have tive, ie, the act of inspiration moves no air due to obstruction in the upper airway, such as the tongue minology, been expected of the inflicter of such knocks, smote him with wonder. falling against the posterior pharyngeal wall. Apnea may d medical occur hundreds of times a night (12). Since the patient "What's the matter?" inquired the clerk. wakes up repeatedly during the night, he or she (much more often a he) is constantly sleepy during waking kwickian"! The astonished boy replied not a word; but hours, just like Joe. Another result of the recurrent f the Pick- he nodded once, and seemed, to the clerk's apneas may be failure of the right side of the heart, t, as Com- imagination, to snore feebly. le Fat Boy resulting from pulmonary hypertension induced by 3e the Fat "Where do you come from?" inquired the clerk. hypoxemia and hypercapnia. ization is,j The boy made no sign. He breathed heavily, but in essiblefor Dickens would also have found it difficult to write about )ntroversy, all other aspects was motionless. the signs of right ventricular hypertrophy and failure he 'charm- The clerk repeated the question thrice, and receiv characteristic of the syndrome without the use of elec aspects of ing no answer, prepared to shut the door, when trocardiography, radiography, or a cardiac cath the boy suddenly opened his eyes, winked several eterization laboratory. One is tempted to believe, on times, sneezed once, and raised his hand as if to the other hand, that had he been trained in and prac 0 types of repeat the knocking. Finding the door open, he ticed medicine, his keen powers of observation may n the first stared about him with astonishment, and at length have led to even more extraordinary descriptions! ive normal fixed his eyes on Mr Lowton's face. :e (2). The Perhaps there are some unknown factors in our knowl fc-entilation "What the devil do you knock that way for?" in edge of the Pickwickian syndrome, as there are in many is the true quired the clerk, angrily. of the beliefs physicians hold as medical facts. Physi cians were arguing over the exact pathology of Joe the "Which way?" said the boy, in a slow sleepy voice. Fat Boy long before Burwell and his coworkers the name "Why like forty hackney-coachmen," replied the first suggested the eponym "Pickwickian" for the thing like clerk. association of extreme obesity with alveolar hypo tto recon-; ventilation. Diagnoses have since ranged from Cush This com- "Because master said I wasn't to leave off knocking ing's syndrome (pituitary basophilic hyperactivity prob "medicine, till they opened the door for fear I should go to ably secondary to disturbed hypothalamic function) (13) an culture sleep," said the boy (6). to narcolepsy (14) to Frohlich's syndrome (obesity, re : in termi-l tarded growth, and genital hypoplasia associated with a In the above passage from Pickwick Papers, we note credit for hypothalamic tumor) (15). Some went so far as to sug Joe's extreme obesity, drowsiness, winking, ruddy Tiption of gest that the Pickwickian syndrome should be called the complexion, and the fact that he "breathes heavily." "Fee-Fi-Fo-Fum syndrome," after the giant in the fairy Dickens does not describe cyanosis. The number of tale, "Jack and the Beanstalk," who shares some of Joe's s, indeed, times he mentions these symptoms is immaterial, al symptoms (16). However, one is tempted to side with •iption ofa though others have complained that a single mention of Robin (10) in the battle to preserve the term "Pick being "red-faced" hardly constitutes polycythemia, nor Jrome": wickian" as a name for the obesity-hypoventilation syn does Joe's heavy breathing represent periodic respi drome. Dickens' 1837 description, today, seems as ac leard at ration (7,9). Consider, however, how many times a curate and edifying as it was in 1956 when Burwell, et al )ck, but physician would write down a symptom or observation (1) paid homage to the great novelist. t of the of "red-faced" on a patient's history. Clearly, ere en- repetition, both in medicine and literature, is con person sidered extraneous. Indeed, it is a valuable exercise for the physician to use literature and art to further his or her medical expertise. Over the years since Burwell's description of the Pick Art and literature, not unlike medicine, are a reflection wickian syndrome, other manifestations have been of the workings of the human mind and spirit. Clearly, noted. Dickens, however, would not have been able to the more aspects of humanity the physician works to chool record these without the tests of modern medical understand, the better he or she will function pro science. For example, he could not explain why Joe was fessionally and personally. William Osier referred to #804, Detroit, so sleepy (as Gastaut, et al (11) did in 1967) without the this oft-ignored avenue of education inhis address "The

25 Markel

Master Word in Medicine": "It is not for all, nor can all to call the disease Joe the Fat Boy of Pickwick Papers attain to it, but there is comfort and help in the pursuit, type of sleep apnea, but it is unlikely that this termi even though the end is never reached" (17). As physi nology would be more effective. Pickwickian syn cians dedicated to the art of medicine, therefore, we drome, as a label to identify obesity, sleep apnea, and must work to appreciate the "virtuosity required of the daytime hypoalveolar ventilation, is not a perfect name,- writer who successfully conveys an understanding of but it does bring art and medicine closer together and humanity just as one admires the diagnostic skills of an serves as a stimulus forthe student of medicine to read a internist" orthe technique of a surgeon (18). It would be Dickens' novel and come to appreciate the writer's more accurate, from a literary and scientific standpoint descriptive talents.

References

Burwell CS, Robin ED, Whaley RD, Bickelman AG. Extreme ob 9. Keelan P. Of Pickwick and Ondine. lr Med J 1981;74(11 ):339-40. esity associated with hypoalveolar ventilation—a Pickwickian 10. Robin ED. Of sleep and seals and many things: Pickwickians — syndrome. Am J Med 1956;21:811-8. 1978. West J Med 1978;129(5):419-21. Kryger MH. Sleep apnea: From the needles of Dionysius to 11. Gastaut H, Tassinari CS, Duron B. Polygraphic study of the ep continuous positive airway pressure. Arch Intern Med isodic diurnal and nocturnal (hypnic and respiratory) mani 1983;143:2301-3. festations of the Pickwick syndrome. Brain Res 1967;2:167-86. Elliot JA, ed. A complete collection of the medical and philo 12. Medical staff conference. University of California at San Fran sophical words of John Fothergill MD, FRS. London: John cisco. The Pickwickian syndrome. West J Med 1977;27:24-31. Walker, 1781:661. 13. Weiner JG. Shut-eye Joe (letter). N Engl J Med 1958;258(10):507. Wadd W. Cursory remarks on corpulence. 3rd ed. London: Callow Medical Bookseller, 1822:177. 14. Bloomberg W. Shut-eye Joe (letter). N Engl J Med 1958; 258(10): 507. Osier W. Principles and practice of medicine. 6th ed. New York: Appleton, 1906:431. 15. Busiek RD. Regarding fat Joe (letter). N Engl J Med 1958;258:1020. Dickens C. The posthumous papers of the Pickwick club. New 16. Phillipson EA. Pickwickian, obesity-hypoventilation or fee-fi-fo- York: Modern Library, 1940:768-84. fum syndrome? Am Rev Respir Dis 1980;121:781-2. Comroe JH. Frankenstein, Pickwick, and Ondine. Am Rev Respir 17. Osier W. The master word in medicine. Aequanimitas and other Dis 1975;111:689-92. addresses 3rd ed. New York: Blakiston, 1942:366. Vaisrub S. Pickwickian syndrome? The Dickens! JAMA 1978; 18. Markel H. Charles Dickens and the art of medicine. Ann Intern 239(7) :645. Med 1984;101:408-11.